Disturbances of the Heart / Discussion of the Treatment of the Heart in Its Various Disorders, With a Chapter on Blood Pressure

by Oliver T. Osborne

The closer a physician is to the laboratory, the less he believes in the value of nitroglycerin in hypertension. The nearer he is to clinical work the more he believes in it. It is a fact that in some instances, even with a dose as small as 1/200 grain of nitroglycerin, three or four times in twenty-four hours, the blood pressure will be lower, whatever the diet is and whatever the other treatments are, than if the patient does not take the nitroglycerin. Also the value of these short relaxation periods from the standpoint of a strained and tired heart should not be underestimated, the same as the value of a night's rest, or the value of a recreation period of an hour or two. If a patient has hypotension and a systolic pressure of 110, and is given nitroglycerin, the very unpleasant results from its administration will be immediately noticed. Hence nitroglycerin is one of the most valuable drugs that we possess for the treatment of hypertension, and some patients are even benefited by as small a dose as l/500 grain. Lawrence [Footnote: Lawrence, C. H.: The Effect of Pressure-Lowering Drugs and Therapeutic Measures on Systolic and Diastolic Pressure in Man, Arch. Int. Med., April, 1912, p. 409.] found that the fall of diastolic pressure from nitrites was about half of the fall of systolic pressure. When there is no kidney lesion a very high systolic pressure falls more under nitroglycerin than does a medium high systolic pressure.

Alkalies, whether potassium or sodium citrate or sodium bicarbonate, are often of advantage in so changing and aiding metabolism, or perhaps reducing the irritation from hyperacidity or a mild condition of acidosis, that their administration causes a lowering of blood pressure.

While iodids may not be direct vasodilators and do not render the blood more aplastic or diminish its viscosity, as shown by Capps [Footnote: Capps, J. A.: Effect of Iodids on the Circulation and Blood Vessels in Arteriosclerosis, THE JOURNAL A. M. A., Oct. 12, 1912. p. 1350.] still, iodids in small doses, 0.1 to 0.2 gm. (1-1/2 to 3 grains) given from once to three times a day, after meals (these small doses do not disturb the stomach), will stimulate the thyroid gland to greater activity, and when this gland secretes properly, the blood pressure is somewhat lowered. Of course, in syphilitic sclerosis large doses of iodids are indicated and are valuable.

In obese patients with hypertension, in the hypertension of women at the menopause, and in hypertension with insufficient kidneys, thyroid medication is often of great value. Sometimes a small dose of from 0.1 to 0.2 gm. (1 1/12 to 3 grains) once a day is all that is needed. At other times, especially when there is no marked arteriosclerosis and no marked kidney or liver lesion, very high blood pressures are reduced only by very large doses, even as much as 10 grains a day. Such treatment is often of very great benefit. Of course, if one of the persons under consideration has symptoms of hyperthyroidism, or if small doses of thyroid cause palpitation, the treatment is not indicated, on the one hand, and should be stopped, on the other. Sometimes when the blood pressure cannot be reduced, in these cases without apparent organic lesions, and thyroid treatment is more or less successful, but at the same time causes great excitation, it may be combined with bromid medication, and then the benefit is sometimes very great.

A patient who cannot sleep and who has hypertension may receive bromids if he is very irritable or if there are symptoms of thyroid irritability; but the most successful sleep and lowering of blood pressure is caused by chloral. A dose of 0.5 gm. (7 1/2 grains) at night is generally sufficient and need not be long continued. Chloral has been frequently given to reduce pressure in 0.2 to 0.25 gm. (3 or 4 grain) doses, three times a day, after meals.

Bromids, of course, will lower the blood pressure, but they depress all metabolism, interfere with digestion, and are not advisable for any length of time. However, in some cases they cause a marked improvement in the patient's condition.

Patients under treatment with chloral, bromids, and thyroid especially, should be carefully watched and the treatment modified to meet the varying conditions. Patients under iodid need not be seen so frequently; those under nitroglycerin or alkalies still less frequently. But all patients under the active management of hypertension should be seen at from one to three week intervals, and the urine should be repeatedly examined and the blood pressure carefully recorded.

HYPOTENSION

A low systolic pressure and a low diastolic pressure may not cause any symptoms or give any cause for anxiety. It does show, especially if the systolic pressure is below normal for the age of the person, a lack of reserve power, and such patients will not well stand serious illnesses, operations, injuries or serious physical and mental strains. If there is a low systolic pressure and a high diastolic pressure, this shows impairment of the heart, whether or not any other organic lesion is present.

Generally speaking, a low systolic pressure shows a weak acting heart muscle, and a very low diastolic pressure shows a dilated condition of the arterioles. In aortic regurgitation this low diastolic pressure is constantly in evidence, and, if the systolic pressure is not below normal, does not signify that the circulation is insufficient. If the systolic pressure is not very low but the diastolic is high, vasodilator drugs, by lowering the diastolic and increasing the pulse pressure, are often of benefit. If there is increased venous congestion and increased venous pressure and a high diastolic pressure with a low systolic pressure, digitalis not only will often raise the systolic pressure, but also will lower diastolic by improving the general circulation and removing venous congestion.